Erectile Dysfunction (ED)

What is erectile dysfunction? 

ED is defined as the inability to get and maintain an erection for long enough to have sexual intercourse[4]. However, you may still be able to get an erection at other times. For example, when you wake up in the morning.   

According to the World Health Organisation, “sexual health is fundamental to the physical and emotional health and wellbeing of individuals, couples and families, and to the social and economic development of communities and countries”[5]  

It is entirely understandable, then, if ED is affecting your mental health. Indeed, individuals with ED are known to have high rates of anxiety and depression[6]. As a result, it is important for individuals with ED to seek mental health support alongside treatment for their ED.  

Erectile dysfunction symptoms 

The symptoms of erectile dysfunction include[7]: 

• Being able to get an erection before sexual intercourse but not being able to maintain it during sexual intercourse 

• Being able to get an erection at random times, but not when you want to have sexual intercourse  

• Not being able to get an erection at all 

• Needing a lot of stimulation to maintain an erection 

ED should not be mistaken for problems with ejaculation. For example, premature ejaculation, when the process of arousal, orgasm and ejaculation occurs too rapidly for satisfactory sexual intercourse. 

What causes erectile dysfunction? 

Previously, ED had been largely thought to be solely caused by psychological issues[8]. However, it is now understood that, for most men, ED is caused by a physical issue.  

An erection begins when aroused nerve impulses travel from the brain to the penis. These impulses trigger the smooth muscle in the penis to relax and allow an increase in blood flow.  

As the penis fills with blood, it gets bigger and more erect. It then compresses the veins which have been preventing blood flow from leaving the area to help sustain the erection. The penis should then stay erect until ejaculation occurs or arousal ends. 

As a result, an erection is dependent on five things[9]: 

• Hormones 

• Blood supply 

• Nerves 

• Tissue 

• Sexual desire 

If one or more of these mechanisms aren’t functioning, an erection is likely to fail. Consequently, there are three main causes of ED:  

• Physical health conditions 

• Psychological conditions 

• Specific medications 

Alternatively, having suffered a head injury, injury to the penis or undergone surgery in that area can sometimes lead to ED.  

Physical health conditions 

There are four main types of health conditions that can interrupt the physical processes required to develop and maintain an erection. These are: 

Vasculogenic conditions 

These affect the flow of blood to your penis. They include: 

• Cardiovascular disease – a build-up of fatty deposits can restrict blood flow[10]. As a result, ED can sometimes indicate an underlying heart problem[11] 

• Hypertension – high blood pressure can damage your artery walls, causing them to harden, narrow and restrict blood flow to the penis[12] 

• Diabetes – sustained high blood sugar over a long period of time can damage the nerves and blood vessels, resulting in restricted blood flow to the penis 

Neurogenic conditions 

These affect your nervous system, which consists of your brain, nerves and spinal cord. They include:  

• Multiple sclerosis – damaged nerve pathways can prevent messages from the brain being sent to the penis[13] 

• Parkinson’s disease – a loss of nerve cells in the brain causes a reduction in a hormone called dopamine that regulates movement. Additionally, symptoms such as muscle rigidity and a tremor can cause a lack of confidence in sexual performance[14] 

• Spinal injuries or disorders – a spinal injury may damage the connection between the brain's centres for sexual function and the penis[15] 

• Stroke – a stroke occurs when the blood supply to the brain is interrupted. Men who have had a stroke have a high prevalence of ED[16]. However, ED is also considered a risk factor for stroke development  

Hormonal conditions 

These conditions affect your hormone levels. They include: 

• Hypogonadism – characterised by abnormally low levels of testosterone, a hormone which enhances libido (sex drive)[17] 

• Hyperthyroidism – an overactive thyroid gland can produce too much thyroid hormone, which is associated with ED [18]. The mechanism behind this association is not yet clear, though hyperthyroidism is associated with a lower libido  

• Hypothyroidism – an underactive thyroid gland results in not enough thyroid hormone being produced. This condition is also associated with a low libido, though a cause has not yet been established[19] 

• Cushing’s syndrome – when your body produces too much of a hormone called cortisol, which helps your body respond to stress[20]. Cushing’s syndrome is also associated with a lower libido  

Anatomical conditions 

Peyronie’s disease is a condition in which fibrous scar tissue forms in the deeper tissues under the skin of the penis. This can cause the penis to bend, get shorter and result in pain during an erection.  

Psychological causes 

The brain is key to sexual desire and developing an erection. If you are struggling with your mental health or experiencing emotional issues, this can prevent you from getting an erection.   

Psychological issues that can contribute to ED include: 

• Depression 

• Anxiety 

• Relationship problems 

• Previous sexual problems 

• Previous sexual abuse  

If psychological issues are causing your ED, you should speak to a healthcare provider about getting support with your mental health.  

Medications 

Certain medications can cause erectile dysfunction, such as: 

• Diuretics – used to treat high blood pressure (hypertension), heart failure and kidney disease 

• Antihypertensives – for example, beta-blockers, which can be used to treat hypertension  

• Fibrates – used to lower cholesterol levels 

• Antipsychotics – prescribed to treat some mental health conditions, such as schizophrenia and schizoaffective disorder[21] 

• Antidepressants – used to treat depression, anxiety disorders and other mental health conditions, such as obsessive compulsive disorder[22] 

• Corticosteroids – also known as steroids, a type of hormone used to treat conditions like lupus[23] 

• H2-antagonists – which can suppress stomach acid production and treat stomach ulcers and acid reflux, among other conditions[24] 

• Anticonvulsants – used to treat epilepsy 

• Antihistamines – taken to treat allergies, such as hay fever 

• Anti-androgens – prescribed to suppresses male sex hormones, such as testosterone 

• Cytotoxics – used in chemotherapy to prevent cancer cells from dividing and growing 

How can erectile dysfunction be treated? 

You will need to speak to a healthcare provider to identify the cause of your ED, as well as the severity, as this will determine the treatment options that could be right for you.  

Your treatment plan may include:  

Erectile dysfunction pills 

The main treatments for ED are a type of medication called phosphodiesterase-5 (PDE-5) inhibitors. These work by relaxing the muscles in the penis to increase blood flow in response to sexual stimulation. As such, these pills only work in combination with sexual stimulation.  

PDE-5 inhibitors are one of the most common forms of medication for treating ED. They are extremely well-studied; at least two-thirds of men report having improved erections after taking one of these medicines.  

They include: 

• Sildenafil (Viagra) 

• Tadalafil (Cialis) 

• Vardenafil (Levitra) 

• Avanafil (Spedra) 

PDE-5 inhibitors don't work for everyone. They may also work less well for people who have diabetes and other conditions or who have just had prostate surgery. If you find that PDE-5 inhibitors are not effective, it may be because: 

• You need to wait longer after taking the dose  

• You have waited too long after taking the dose 

• You need a higher dose  

• You are not sufficiently sexually stimulated  

Each PDE-5 inhibitor works slightly differently and has different benefits and draw backs. Your GP should explain these to you and work with you to find the right medication and dosage for you. 

Side effects 

Possible side effects of taking PDE-5 inhibitors include:  

• Headaches and migraines 

• Flushing (redness)  

• Indigestion 

• Nausea (feeling sick) 

• Vomiting (being sick) 

• A blocked or runny nose 

• Back pain 

• Vision changes 

• Muscle pain 

• Stomach upset  

Warnings 

PDE-5 inhibitors should be used with caution in individuals who:  

• Have cardiovascular disease 

• Have Peyronie’s disease 

• Are at risk of priapism (a long-lasting, painful erection) 

• Are taking long-lasting alpha-blockers (used to treat conditions such as hypertension) 

• Are taking medicines or recreational drugs that contain nitrates  

• Have been advised not to take part in sexual activity  

• Have low blood pressure (hypotension)  

• Have recently had a stroke  

• Have unstable angina (a heart condition) 

• Have had a heart attack  

• Have a history of non-arteritic anterior ischaemic optic neuropathy (an eye condition) 

Alprostadil 

Alprostadil is a synthetic (man-made) hormone that helps to stimulate blood flow to the penis. It will usually produce an erection within five to 15 minutes.  

Alprostadil is available as: 

• Self-injection therapy – you will use a fine needle to put alprostadil (Caverject, Edex) into the base or side of your penis. Because you use a very fine needle, pain from the shot should be minimal. Alprostadil will cause an erection lasting no longer than an hour 

• Urethral application – you will place the medicine inside your penis into the tube that carries urine from the body (urethra) using a special applicator 

Side effects 

Possible side effects of using alprostadil include: 

• Blood pressure changes 

• Headaches 

• Swelling or other reactions at the site of the injection 

• Pain in your penis  

• Urethral burning or bleeding 

• Dizziness 

Warnings 

Alprostadil should not be used in individuals who: 

• Are at risk of priapism  

• Take other ED medications  

• Have a penile implant  

• Have been advised to avoid sexual activity  

• Have Peyronie’s disease 

• Have an infection in their penis 

Hormone replacement therapy 

If your ED is caused by a hormonal condition which causes low levels of testosterone, you may be prescribed hormone replacement therapy. This treatment uses injections of synthetic hormones to normalise your testosterone levels and is often used alongside other ED treatments.  

Penis pumps 

A penis pump, also known as a vacuum pump, is a plastic tube that fits over your penis. A hand or battery-operated pump attaches to the tube and sucks the air out. This creates a vacuum that pulls blood into your penis to make it erect. 

Once you get an erection, you put a rubber tension ring around the base of your penis to hold in the blood and help you maintain the erection. You then remove the vacuum device. 

The erection generally last around 30 minutes. Once you’ve had sexual intercourse, the tension ring can be removed.  

Penis pumps are generally very effective. Nine in ten men report being able to have sex after using one, regardless of the cause of their ED. Additionally, around three-quarters of men report being satisfied with the results of this type of surgery. 

Side effects 

Side effects of vacuum pumps include:  

• Pain or bruising 

• Weakened ejaculation 

• A cold penis to the touch 

Warnings 

You should not use a vacuum pump if you:  

• Have a bleeding disorder 

• Are taking anticoagulant medication, which prevents blood clots 

Surgery 

Penile implants may be considered if all other treatment methods have failed. Alternatively, they may be suggested for younger men who have ED due to a serious injury or anatomical problem.  

These can be: 

• Semi-rigid implants – which keep your penis firm but can be bent away and toward the body, depending on when you do and don’t want it to show 

• Inflatable implants – which can be inflated to provide you with control over when and for how long you have an erection 

Warnings 

As with any surgery, penile implants come with a risk of complications, such as infection. However, if you take preventative antibiotics, the rate of infection is around two or three in 100.  

It’s worth noting that penile implants are not usually available on the NHS and inflatable implants can be very expensive. Additionally, mechanical issues with the implants sometimes occur within five years of the surgery. However, this is only in five per cent of cases.  

Mental health support 

If your ED is thought to be caused by anxiety, depression, or other emotional concerns, you may be recommended to see a counsellor or therapist.  

Common forms of therapeutic intervention used to treat ED are:  

• Sensate therapy – sex therapy that involves you and your partner abstaining from sexual intercourse for a period of time while you explore each other’s bodies without sex being the primary focus  

• Psychosexual counselling – relationship therapy where you and your partner can discuss and potentially overcome any sexual or emotional issues that may be contributing to your ED 

• Cognitive behavioural therapy – therapy designed to help you to identify and overcome any unhelpful or unrealistic thoughts that may be causing your ED 

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